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-_ _ -----=ia_.: _:.:J • ed:�s:;5�'�:ati+S�S�eb?:iaMs_'.3T:a . A1�,m3�5�i111'W�90lia+-ti-vWl . — -- ---+ca�.u::.,:� ...ovvs.�..i --- -.r.u:W.:.......�:.z:.ativ.-__:�_=v.=�,.Y� _ ,...... <br />Waste Tire Survey & onspecti®n Repo <br />CalRecycle State of California <br />CalRecycle 181 (Rev. y (Cal Survey Form - Page I <br />Dept of Resources Recycling and Recovery (CalRecycle) <br />)art A - Survey <br />Business Profile Inspection Details <br />TPID -Inspection Type (Fill one) <br />Site Suffix: �) I Cl `7 / ft Routine Q Re -inspection Q Referral Q Observation <br />Inspection Report Number <br />I1 - 1245085 <br />BLUE OR BLACK INK PEN <br />Local <br />Identifier: <br />Business or Facility Name <br />Physical Address <br />(0 I l fj . -6 Y cl t <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />- 1 v 1 S v c (AO -R, <br />�t rm <br />JInspection <br />C if <br />Date <br />4 / <br />Time In <br />Business Rep <br />Title <br />0 AM <br />�^ <br />�j®PM <br />A <br />Operational Status <br />Tire Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that appl) <br />Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />O <br />GPS Latitude <br />, <br />Q Inactive <br />® Truck <br />O <br />Longitude — <br />Q Planned <br />® OTR <br />Business Type (Fill all that apply) <br />Q New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A I HAULING AND MANIFEST REQUIREMENTS <br />Q Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q Q PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q Q 14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q Q 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q Q 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q Q 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Q 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q Q 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0101 Other: § <br />Comments �i; a . i :. _ a . J_ _ <br />21 / 1 <br />Time Out <br />( O AM <br />qPPM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />Generator 0 Outdoor <br />Q Hauler I ® Indoor <br />Q End -Use 10 Container <br />Dismantler O Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem <br />(Required for NOV or EXT N <br />a <br />0 <br />Q Referred / CalRecycle Enforcement <br />Lu <br />W <br />® In Compliance - No Violations <br />V <br />Inspection Form Included: U <br />Comments Included: 0 <br />Business Rep's Signature Phone Number Inspe or's ure Phone Number <br />INSTRUCTIONS ON BACK I Correct* Incorrect:X7*A EXAMPLE 1 2 3 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />